Adrenal Reaction re: Armour Allergy

[Guest guest]

I just found this article on Dr. Lowe and I thing it

is germaine to the discussions we have been having.

Whether someone takes or doesn't take medications,

and/or the amount of those medications isn't

necessarily the issue. Why they are needed is a

primary issue, IMHO.

Adrenal Glands

[Q & As are placed in reverse chronological order. In

other words,

the latest Q & As come first. Earlier ones are further

down the page.]

February 22, 2007

Question: My doctor diagnosed low cortisol and has me

taking 20 mg of cortisol each day. I am concerned

about taking too much, but she told me that 20 mg is a

safe dose. What are the symptoms of too much cortisol

so that I can watch for them? How much cortisol is too

much?

Dr. Lowe: I have included below a list of the

symptoms, signs, and test results when patients have

severe excess cortisol. Keep in mind that factors

other than excess cortisol can cause most of these

symptoms, signs, and test results. Because of this,

just because you have one or more of these features

doesn’t necessarily mean you’re taking too much

cortisol.

Also bear in mind that what is too much cortisol for a

patient is an individual matter: What is too much for

one patient may be too little for another, and vice

versa. Moreover, some patients’ tissues are partially

resistant to cortisol, and they have to maintain a

higher body level of cortisol than others to be free

from cortisol deficiency symptoms and signs. Cortisol

resistance is now a scientifically established

disorder, but I don’t believe researchers have

established the incidence in the population. If a

patient suspects he has cortisol resistance, it is

crucial that he work with a doctor who is

knowledgeable about the disorder and experienced in

working with cortisol resistance patients.

My treatment team has worked with some patients who

over medicated themselves with cortisol. The patients

developed the symptoms and signs of cortisol excess

only after several months of taking very large daily

doses—several times the 20 mg you’re taking.

As I said, though, how patients respond to different

doses of cortisol is an individual matter. Because of

this, it’s hard to say what will be excessive for any

particular patient. However, it is important for

patients to stay within the range considered

“physiologic” rather than “pharmacologic.”

“Pharmacologic” refers to the large doses of cortisol

analogues (such as prednisone) that doctors

use—hopefully briefly—to suppress inflammation.

Pharmacologic doses are often used to treat conditions

such as severe acute asthma.

“Physiologic” refers to maintaining a body level of

cortisol that the adrenal cortices would maintain,

were they capable of doing so. One aim, then, of

physiologic cortisol therapy is to give the patient

just enough cortisol to make up for what his adrenal

cortices should be but aren’t providing.

Because of individual variability, it’s best for each

patient to work with a knowledgeable doctor to decide

what is for that patient a physiologic dose. But I

agree with your doctor: your dosage of 20 mg is mostly

likely well within the harmless physiologic range.

Symptoms, Signs, and Test Results in Cortisol Excess

O Weakness O Reduced resistance to infection

O Muscle wasting O Edema

O Poor wound healing O Easy bruising

O Obesity of the trunk of the body O Purple striae

(stripes) on the abdomen

O Fat pads above the collar bones O Fat collection at

the junction of the back of neck and upper back

( " buffalo hump " )

O Skin that is thin and atropic O Plethoric (overfull,

turgid, inflated) appearance

O Rounded " moon " face O High sodium & low potassium

levels

O Psychological disturbance such as mood swings O

Slender arms and fingers and legs and toes

O Glucose intolerance O Excessive hair growth

(hirshutism)

O Kidney stones O Menstrual irregularities such as

amenorrhoea (absence of periods)

O Osteoporosis O High blood pressure

December 10, 2006

Question: I am a 46-year-old woman who has been

hypothyroid for twenty years. The general practitioner

who diagnosed my hypothyroidism put me on Thyrolar. I

did well on that for years. When I saw an

endocrinologist for another problem, she took me off

the Thyrolar and prescribed Synthroid. She told me

that Synthroid was the standard of practice. Within

three months, I had gained fifteen pounds and was

severely depressed. My general practitioner prescribed

an antidepressant for the depression and told me to

exercise more to lose the weight. Out of frustration,

I found a new general practitioner, and he prescribed

Armour Thyroid. Six weeks later, my weight was down

and the depression was gone.

About a month after I started the Armour, a new

problem came over me. My joints became swollen and

painful. My finger and wrist joints are worse, but my

shoulder and hip joints also hurt. A rheumatologist

who gave me a cortisone shot, and the pain was gone

for about a week. When the pain came back, he told me

to take ibuprofen to keep the pain down. I’m doing

that, but my joints still hurt and I’m afraid of side

effects of the ibuprofen. Do you think I became

allergic to something in the Armour? Should I switch

back to the synthetic hormone in Synthroid to see if

that makes the pain go away?

Dr. Lowe: I'm sorry you have joint swelling and pain,

and that you’re confused about what brought it on. I

think it is highly unlikely that you’re allergic to

anything in the Armour pills. A way to eliminate that

possibility, however, is to take an antihistamine that

you know is effective for you. If the antihistamine

makes the swelling and pain go away, stop the

antihistamine. If the swelling and pain return, start

the antihistamine again. If the symptoms again subside

or fully go away, you can be confident that an allergy

is causing the symptoms.

As I said, though, I think that’s not likely. I have

two reasons for saying this. First, the

rheumatologist’s cortisone injection stopped the

swelling and pain for a time. Cortisone is an

anti-inflammatory drug, and because it stopped the

swelling and pain, the cause is most likely

inflammation.

My second reason for saying an allergy isn’t likely

the cause of the symptoms is more important. That

reason is that I've had many patients who had

essentially the same history as you. They had joint

swelling and pain after switching to a more effective

thyroid hormone therapy. (Most often, patients had

switched from a T4-only product, such as Synthroid or

Levoxyl, a T4/T3 product such as Armour, Westhroid, or

Naturthroid, or to T3 alone.) I then diagnosed a

cortisol deficiencies through salivary free cortisol

testing. Next, we corrected their deficiencies with

physiologic cortisol therapy, and this eliminated

their joint swelling and pain.

If you’re truly like those patients, what probably

happened to you is this: Synthroid was not effective

enough to keep your liver’s metabolism at a normal

rate. Because of this, your liver sluggishly cleared

cortisol from your blood. For some reason, the cortex

of your adrenal glands can’t produce a normal amount

of cortisol. But, using Synthroid and only slowly

clearing cortisol out through your liver, you still

had enough cortisol in your body to inhibit

inflammation.

But when you switched to Armour, it sped up your

liver’s metabolism. As a result, your liver began

clearing cortisol from your body more quickly. But

your adrenal glands can’t produce enough cortisol to

make up for the larger amount your liver is clearing

from your body. Because of this, the faster clearance

has lowered your body’s cortisol too far. Having too

little of this anti-inflammatory hormone has led to

your symptoms: joints that are swollen and painful

from inflammation set off the mechanical stresses of

joint movement and weight bearing.

If a cortisol deficiency has caused your joint

swelling and pain, switching back to Synthroid is not

the prudent course of action. Synthroid might free you

from the joint swelling and pain by letting your liver

again clear cortisol from your body too sluggishly.

But you would most likely gain weight again and sink

back into depressed. What is prudent is to stay on

Armour Thyroid, which is more effective for you. Then

confirm that you have a cortisol deficiency, and

correct it by using physiologic cortisol therapy.

December 14, 2003

Question: I took Armour Thyroid for a month. It

relieved most of my hypothyroid symptoms, but then I

began to have severe joint pain. I’ve now been off the

Armour for six weeks. My old hypothyroid symptoms have

returned, but the joint pain has stopped. My

endocrinologist prescribed the Armour, and he was very

surprised. He’s never had another patient who had this

problem. I contacted Forest Pharmaceuticals, the

manufacturer of Armour, and they said they had six

other cases like mine. When the patients took Armour,

they developed joint pain, and the pain went away when

they stopped taking Armour. Forest also found a French

study that discussed a correlation between

hyperthyroidism and joint pain. My endocrinologist is

going to let me try a combination of Synthroid and

Cytomel. If the combination gets rid of my symptoms

and I don’t develop joint pain again, we’ll know it

was the Armour that caused the pain. Maybe I had an

allergy to Armour. What do you think about all this?

Dr. Lowe: It’s within the realm of possibility that a

patient could have joint pain as part of an allergy to

some chemical constituent of Armour. But I seriously

doubt that this was the mechanism of your joint pain.

The most likely mechanism is a cortisol deficiency

stimulated by an effective dose of Armour. An

effective dose of thyroid hormone increases the

metabolism of the liver. Increased liver metabolism

speeds the rate at which the liver clears various

hormones, such as cortisol, from the blood. If the

patient’s adrenal cortices aren’t capable of

increasing their production of cortisol, the patient

can develop a cortisol deficiency. Cortisol is an

inflammatory hormone, and a deficiency of it can cause

some tissues to easily become inflamed. Joints are

highly susceptible to inflammation during a cortisol

deficiency. The reason is that they’re often subjected

to mechanical stresses, such a movement and pressure.

If a cortisol deficiency was the mechanism of your

joint pain, I would expect an effective dose of

combined Synthroid and Cytomel to induce the pain

again. To validly test for this mechanism, you should

use the same ratio of T4 to T3 as in Armour (a 4-to-1

ratio). You should also take as much T4 and T3 as you

were getting in the dose of Armour when the pain

occurred.

If the pain reappears while you’re using Synthroid and

Cytomel, your next step should be adrenocortical

testing. You should get several measures of your

salivary cortisol through a 24-hour period. Possibly,

you should also undergo an ACTH-stimulation test. In

that test, you’ll have an injection of ACTH, and the

change in your cortisol level will be measured. You

should, of course, still be using Synthroid and

Cytomel when you undergo the testing.

Your endocrinologist may order or perform the ACTH

test. However, most conventional doctors still don’t

test for levels of cortisol in saliva. If your

endocrinologist isn’t familiar with the saliva test,

we’ll be happy to order it for you.

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